Putting Perspective on the Rural Provider

Two long term and post-acute care (LT/PAC) leaders offer their own insights on life for a rural provider in 2019, describing how finding staff is just one of the clear-cut challenges ahead for small-town owners and operators. 
They also say that while the task of being a provider in the small locales across the country may be daunting, taking an aggressive approach to giving residents high-quality care and devising a solid business plan are critical.
Gail Sheridan, registered nurse, chief clinical operations officer and a principal of Tealwood Senior Living, which operates more than 40 skilled nursing and assisted living communities in the Midwest, knows things are not easy.
She says the work of providing care has many barriers these days, especially in what Sheridan says are some of the “very rural” facilities her company runs. The very nature of being rural means that a hospital may be 30 or 40 miles or more from the nursing center, with a lack of readily available medical services all along the care continuum.

A related challenge is the difficulty in finding and maintaining good medical directors. “Keeping physicians is very difficult in those areas, it is very difficult. And the medical director position for a LTC facility for us is a very important position and certainly helps us with our practice and our infection control and all the requirements that go with the Requirements of Participation,” Sheridan says.
The demographic shift is also pronounced, with the younger people in many rural locales moving away and the older people often staying put if they do not follow their adult children to more urban settings.

“We struggle in some locations. We are blessed that we have a lot of longevity [in staff], but with that we also have some workers that are well past retirement age. We worry about replacing them at some point,” she says.

Attacking the Workforce Problem

On staffing, Tealwood has a multi-pronged program in place to deal with recruitment and retention, namely to create a winning work environment for existing employees.
Sheridan says the company works hard to provide a positive environment and meet individual staff needs as well. “Like most providers, we certainly do an annual survey of our staff so that we can find out how we are doing as leadership. Are we meeting their needs, and what other things could we be doing?” she says.

Tealwood has completely revamped its orientation for new employees, based on feedback from staff, to make it more mainstream and meaningful. In that vein, the company is a big believer in regular check-ins with new employees within the first 60 or 90 days, Sheridan says.

The process involves an executive director sitting down with a new employee on the seventh day of employment to conduct a nonconfrontational, friendly chat covering items like orientation, making friends on the job, and reviewing their experiences. This review is repeated at 30 and 60 days and has helped in keeping staff, she says.
Other programs offer tuition assistance, student loan repayment aid, and scholarship programs to help defer the cost of staff looking to make LT/PAC a career, often by becoming a nurse.

“That is a way to retain people and also to keep people in our profession,” Sheridan says. “We also diligently work with high schools, we reach out to colleges, we go onsite to colleges, we do education, we do networking.” All of the outreach has the goal of attracting younger workers and showing how the profession can be a solid career, beyond being a first job.

Active in the Community 

The comprehensive campaign to keep rural communities open and thriving is important for not only Tealwood, but also the larger population, Sheridan says, stressing that in many cases the nursing center is the largest employer in any given small town it operates.
“We do pay taxes. We support our local schools through events and sponsorships and our local businesses,” she says. “Our executive directors are frequently on the chamber of commerce. They participate in doing their civic duties that way. They host meetings for the community. One of our skilled buildings had Weight Watchers wanting to meet there since they had no place to meet.”
The goal is to do anything possible to open the doors and bring townspeople in. “We are definitely a significant part of the community. We obviously are, our employees have children who go to the schools…we are all kind of dependent on each other,” Sheridan says.
And, talk of what would happen if this pulling together does not work is a concern that hangs over some of the conversations in small towns. “In South Dakota, there were a couple of facilities that announced closures in the rural areas, and we all have talked about what is going to happen to those communities because they are the main employer in those communities,” she says. 

Taking Care of Business

A second leading voice on rural provider issues is Robert Siebel, president and chief executive officer of Carriage Healthcare Companies, a multistate operator of long term care facilities, as well as a consulting firm providing services to facilities, financial institutions, and other entities interested in the field of long term care.
His definition of rural is communities that are not too close to a big or medium-size metro area. Carriage is nearly all defined as rural, with every one of its facilities in towns from as small as 720 to as large as 9,000 to 10,000 people. Siebel says the bulk have a residential population of around 1,200.
Each of the communities in which care is provided share a common trait, which is that almost all of them are at best staying even, with population in many cases getting smaller. 
“National numbers used to be 60 to 65 percent rural and 35 percent urban, and now it is flipped,” he says. “So, all these little towns, they are struggling to maintain population in virtually every case, certainly from a staffing standpoint.”

Viable or Not?

When asked if being a rural provider is a viable business these days, Siebel says that all depends on the individual market and what is out there in the way of competition.

One of the two big contributors is critical access hospitals, he says. “They are definitely a challenge because in these small towns, if there is a critical access hospital, they often are siphoning off a lot of what would normally be admissions to a SNF and simply keeping them.”
The other barrier to success for a rural provider is what Sheridan spoke of: the lack of physicians or nurse practitioners, as well as therapists and other medical professionals. 

“They are not flocking to a town of 1,200 people,” Siebel says. “We have a case in a 50-bed home of ours in Wisconsin, where there is no hospital, there is no doctor. So that impacts our admissions because if somebody needs quite a bit of care, particularly newer admissions that are recovering, they don’t want to be transported 20-30 miles to see a doctor or get a therapy treatment.”
Still, Carriage has no intent to move away from the rural provider model that is its business, he says. Even with the population losses, there will be no wholesale retreat from rural areas.

He cites the success of Carriage’s Maple Ridge Center in Spooner, Wis., as an example of how all is not doom and gloom by any stretch. “In Spooner, where they have 2,600 people, that home stays pretty full at 90-plus percent occupancy. But there are other facilities of a similar size that can’t get there and are struggling at 80 percent,” Siebel says.

Rethinking Possibilities 

There are steps being taken to change the care model where few clinicians are locally available, he notes, pointing to the favorable possibilities of telemedicine, which Carriage believes in strongly and currently has available in two of its communities.
“We are hoping to get it in more, but in some cases we are having a hard time with acceptance [from facility-tied physicians],” he says, adding that a facility is in a “fickle spot” if the practitioner does not want to take part in telemedicine. “Where we have had acceptance, it’s a big plus. I am a huge fan of telemedicine,” Siebel says.

There are many positives about being a rural provider, he says, starting with the fact most often the center is the major provider of health services.
“In the majority of our communities we are the sole provider, so yes that is clearly an advantage. The other big one is that you are a real force in the wider community. You have the ear of the community when you are the largest employer, which we are in quite a few cases. Even if not, you are in top two or three. That is a big piece of it,” Siebel says.

With this power brings real responsibility and the corresponding role of being a focal point of civic activity. Carriage facilities are apt to be the host of any number of types of events, such as being the home to a foot clinic once a month to the town as a whole.
“This is a real popular event, it is crazy and a big deal,” Siebel says. “People donate $5 if they can. If they cannot, it is free. It’s a social occasion. Everybody comes and has a nurse look at their feet.”